Strengthening implementation of integrated care for small and nutritionally at‐risk infants under six months and their mothers: Pre‐trial feasibility study

An integrated care pathway to manage small and nutritionally at‐risk infants under 6 months (u6m) and their mothers (MAMI Care Pathway) is consistent with 2023 WHO malnutrition guidelines and is being tested in a randomised controlled trial (RCT) in Ethiopia. To optimise trial implementation, we investigated contextual fit with key local stakeholders. We used scenario‐based interviews with 17 health workers and four district managers to explore perceived feasibility. Eighteen policymakers were also surveyed to explore policy coherence, demand, acceptability, evidence needs, opportunities and risks. The Bowen feasibility framework and an access to health care framework were adapted and applied. Health workers perceived the MAMI Care Pathway as feasible to implement with support to access services and provide care. The approach is acceptable, given consistency with national policies, local protocols and potential to improve routine care quality. Demand for more comprehensive, preventive and person‐centred outpatient care was driven by concerns about unmet, hidden and costly care burden for health services and families. Inpatient care only for severe wasting treatment is inaccessible and unacceptable. Support for routine and expanded components, especially maternal mental health, is needed for successful implementation. Wider contextual factors may affect implementation fidelity and strength. Policymakers cautiously welcomed the approach, which resonates with national commitments, policies and plans but need evidence on how it can work within varied, complex contexts without further system overstretch. A responsive, pragmatic randomised controlled trial will generate the most useful evidence for policymakers. Findings have informed trial preparation and implementation, including a realist evaluation to contextualise outcomes. A formative feasibility study investigated factors that may influence implementation of the MAMI Care Pathway during a randomised controlled trial in Ethiopia. Health workers perceived it was feasible to implement with support. Policy‐makers need evidence on how it works. Findings strengthened implementation plans and informed a process evaluation to accompany the trial. Key messages The MAMI Care Pathway integrated approach is perceived as acceptable, needed and possible to implement during a randomised control trial in outpatient clinics in Ethiopia. Contextualised inputs (training, staffing, space and supplies) will be needed to stren